1982764858 NPI number — DR. PAULINA JOSE AVENDANO MD,FAAP

Table of content: DR. PAULINA JOSE AVENDANO MD,FAAP (NPI 1982764858)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982764858 NPI number — DR. PAULINA JOSE AVENDANO MD,FAAP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AVENDANO
Provider First Name:
PAULINA
Provider Middle Name:
JOSE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD,FAAP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982764858
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
638 CAMINO DE LOS MARES
Provider Second Line Business Mailing Address:
H130-403
Provider Business Mailing Address City Name:
SAN CLEMENTE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-682-5738
Provider Business Mailing Address Fax Number:
949-326-0606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 AVENIDA VISTA HERMOSA
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
SAN CLEMENTE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-429-7700
Provider Business Practice Location Address Fax Number:
949-429-7704
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  G077201 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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